Analysis of clinical manifestations of lumbar spinal stenosis

Lumbar spinal stenosis (PSS), being well determined from the morphological point of view, is heterogeneous in clinical manifestations. Polymorphism of clinical syndromes in patients with lumbar spinal stenosis suggests diffuse morphological changes in the structures of the spinal canal and their ambiguity.

The walls of the spinal canal are lined with the outer plate of the dura mater of the spinal cord and are formed by the bony formations (the posterior part of the vertebral body, the roots of the arches, the arcuate joints) and the ligamentous (posterior longitudinal ligament, yellow ligaments) and the intervertebral disc. Each structure can play a role in the clinical syndromes of lumbar spinal stenosis.

The clinical nucleus of lumbar spinal stenosis is represented by a variety of pain, neurodystrophic and vegetative-vascular disorders, which are also, as a rule, subcompensated and slightly affect the quality of life of the patient. According to LA Kadyrova, from the clinico-anatomical point of view, lumbar spinal stenosis continues to be a Cinderella in modern neuro-orthopedics.

According to the data of magnetic resonance imaging analyzed by us, the basis for the mechanisms of the formation of lumbar spinal stenosis are hyperplastic and dislocation processes in the spine: a decrease in the height of the disk, antelisthesis, retrolistesis and laterolistesis of the vertebrae, dislocation of arched joints, osteophytes of vertebral bodies, hyperplastic deformation of arches and articular processes, osteophytes of articular facets, hypertrophy and ossification of the posterior longitudinal and yellow ligaments, leading to a decrease in the size of the central hour spinal canal, lateral pockets.

Obviously, to reveal the mechanism of the formation of clinical manifestations of lumbar spinal stenosis, it is necessary to compare the maximum number of clinical syndromes with the data of radiation and magnetic resonance imaging of the lumbar spine.

The aim of our work was to analyze the features of clinical manifestations of lumbar spinal stenosis in patients.

A total of 317 patients aged 48 to 79 years who were on treatment at the "IPPs im. MI Sitenko of the National Academy of Medical Sciences of Ukraine "from 2008 to 2011, who was diagnosed with a lumbar spinal stenosis as a result of a clinical radiology and MRI study. Patients were divided into two groups: the I group (n = 137) consisted of patients with PSS and the presence of persistent neurologic deficit, group II (n = 180) - patients with PSS and signs of objective transient neurologic disorders.

All subjects underwent a comprehensive clinical and neurological examination, a study on the scale of the quantitative evaluation of the severity of neurologic disorders (Z), the scale of the general severity of the disabili- tation before and after treatment (Oswestri), the JOA scale (scale of the Japanese orthopedic association), the ASIA scale, the life of Barthel (Barhel ADL Index).

Statistical processing of the results was carried out using the program Statistica v. 6.1 (StatSoft Inc., USA). The degree of interrelation of individual indicators was calculated by the methods of pair and multiple correlation analyzes. The reliability of the differences was determined with the use of the t-test of Student.

More often the first symptom was algic, of varying degrees, in the lumbar region (in 94.95% of patients) with irradiation to the lower extremity (s) (in 78.86% of patients). The duration of the lumbar period was different - from several days to several years, then the radicular pain in one or two legs was attached. A detailed history of the anamnesis allowed us to distinguish two groups of patients: with a progressive-remitting course and with a recurring course of the disease. In the first case, there was a steady increase in the pain syndrome and each subsequent exacerbation was accompanied by a decrease in the distance traveled, that is, signs of claudication formed. In the group with a recurrent course, there was an increase and decrease in the pain syndrome, however, according to the patients, this did not affect the duration of walking. Interesting, in our opinion, was the fact that the majority of patients with a progressive-remitting course of pain syndrome were represented by patients of Group I.

The results of our observations showed that one of the earliest signs of lumbar spinal stenosis is painful convulsions (crampies), a peculiar and poorly known sign of lumbar spinal stenosis, related to paroxysmal impairment of the function of the peripheral nervous system. In our study, they were observed in 39.41% and 21.11% of Group I and II patients, respectively, but more often in patients with lateral stenosis and lesion of several roots on the one hand. Crumpies appeared together with the first pain sensations in separate groups of muscles, more often in calves, less often in the gluteal muscles and the leading muscles of the thigh.

The level of the JOA score was higher in Group II patients, which, in our opinion, is absolutely justified because there are no signs of a neurological deficit in this category of patients. The ADL-scale showed a decrease in the level of daily activity in groups without a statistically significant difference. The mean values of the overall severity of neurologic disorders were the lowest in the group of patients with central stenosis, the mean values of the Z scale in Group I patients showed the presence of more severe neurologic changes in patients with lateral stenosis. When examining the dependence of the indicators included in the Oswestry Index Questionare, it was found from the observation group that the presence of neurological disorders, as expected, worsened the well-being and, correspondingly, the quality of life of patients with lumbar spinal stenosis.

The average number of points of the sensitive and motor parts of the ASIA scale corresponded to the level of radiculo-caudal deficiency present in patients and indicated a more severe lesion of the cauda equina root in subgroups with lateral and combined lumbar stenoses.

The classic and most frequent manifestation of lumbar spinal stenosis, according to the literature, is neurogenic intermittent claudication (NPH). This is confirmed by our research. Anamnesis in almost all patients revealed clinical precursors of neurogenic intermittent claudication as an enhancement of the pain phenomenon or transient symptoms of prolapse, the appearance of pain, numbness and weakness in the legs when walking; the symptoms regressed when the patient stopped and leaned forward.

Neurogenic intermittent claudication was noted in 81.02% of Group I patients and in 76.66% of Group II patients and in our study was divided according to the clinical and topographic feature into caudogenic and radiculogenic lameness. The most common form of claudication was cudogens intermittent claudication - in 64.86% of patients in Group I and in 70.29% of patients in Group II; one-sided radiculogenic lameness was observed in 35.14% and 29.71% of patients, respectively. Most often, caudogenic plaque was found in the group of patients with combined stenosis of the spinal canal - in 36.93% and 40.58% of patients in 1C and 2C subgroups, respectively.

Sharply expressed claudication (<100 m) was noted in 24.32% of Group I patients and in 30.43% of patients in Group II. As a pronounced claudication, the distance from 100 to 200 m was estimated at the march test (28.82% and 28.98% of patients, respectively). Moderate claudication (200-500 m) was detected in the majority (46.85% and 40.58% of the patients of the observed groups). There were no statistically significant differences in subgroups.

Among those under 54 years of age, the highest incidence of severe claudication was observed, 15.67% of patients. In the age group from 55 to 71 years, all the severity of claudication occurred with about the same frequency. In the group of patients older than 72 years, claudication was more often moderately expressed (16.06%).

We observed a direct correlation of NPH with excess weight and chronic venous insufficiency of the circulation in the lower extremities (p <0.0005, g = 0.77). A less strong but statistically significant correlation of NPH was found with hypertensive disease (p <0.0021, g = 0.64). There was no statistically significant difference between subgroups.

Our data show that, most often, the observed patients had radicular syndrome in 125 (91.24%) patients of group I. Monoradicular syndrome was more often diagnosed in subgroup IB (30%), biradiculopathy with equal frequency occurred in subgroups IA and 1C (24.14% and 24.49%), compression was more often polyradicular in patients of subgroup 1C (18.97%); in subgroup IB, polyradiculopathies were not noted.

Sensitive changes did not have a specific character, depending on the observation group. Movement disorders were diagnosed in 86.13% of Group I patients. The decrease in muscular strength in the extensor (25.55%) and the flexor of the feet (18.98%), weakness of the long extensor of the big toe and the quadriceps muscle of the thigh was noted predominantly in 14.59% of patients, triceps muscles in 10.94% which corresponded to the level of lumbar spinal stenosis. Among patients with group I with central stenosis, the severity of paresis was often limited to 3-4 points (84.44%). At the same time, among patients with mixed stenosis pareses met with the same ratio of moderate and significant motor disorders (42.25% and 40.84%, respectively). In patients with lateral stenoses pareses were found in 72.41% of cases, while the ratio of moderate to significant paresis was not statistically different (35.71% and 38.09%).

Vegetative disorders were observed in 30.61%, 63.33% and 55.17% of patients, respectively, in the form of sensation of cooling and hyperhidrosis on the affected limb. Hypotrophies of the leg muscles, gluteus muscles were moderate and always corresponded to the innervation zone of the affected root and, regardless of the group, were more often observed in patients with lateral stenoses (66.67% of patients).

Sphincter disorders were absent in patients with lateral stenoses and were more often observed in the group of patients with combined lumbar spinal stenosis - 37.93%.

We found a positive correlation (p <0.05, g = 0.884) between hypertrophy of the arcuate joints and increased pain syndrome in stress tests. In addition, in patients with spondylarthrosis, we noted significantly lower (5.9 + 1.13) JOA scores (p <0.05), ie, these patients had a worse functional condition of the lumbar spine compared to patients without spondyloarthrosis changes (6.8 ± 1.23).

So, our study confirmed the polymorphism of clinical syndromes in patients with lumbar spinal stenosis. The results of complex diagnostics in lumbar spinal stenosis make it possible to state that only a comprehensive examination of patients using not only visualization methods of investigation but also detailed clinical analysis will enable to develop rational treatment tactics and predict the outcomes of the disease. To reveal the mechanism of the formation of clinical manifestations of lumbar spinal stenosis, it is necessary to compare clinical and visualization data, as well as to take into account the revealed correlations.

Cand. Honey. Sciences of I. F. Fedotov. Analysis of clinical manifestations of lumbar spinal stenosis // International Medical Journal №4 2012

[1], [2], [3], [4], [5], [6], [7], [8], [9],